Management principles for articular fractures―How do they differ from diaphyseal fractures? Acknowledgements: Cleber AJ, Paccola BR Mahmoud Odat, JO AOT Basic Principles Course

Learning outcomes Describe the healing mechanisms of articular cartilage and how they can be impacted by different treatments Appreciate the importance of anatomical reduction, rigid fixation, and early active movement for treatment of the articular surface, including the importance of restoring the correct mechanical axis Discuss the early management of articular fractures with severe soft-tissue injury (bridging external fixation, staged procedures) Teaching points: Anatomical reduction for articular surfaces must be combined with absolute stability to achieve healing with no callus. Length and alignment of an extremity should be attained before attempting approach and reduction of articular surfaces.

Reduction? Stability? Implants? Healing? This is a case of intra articular fracture At the end of the lecture we should answer the follpwing questions What type of reduction, stability, is needed? The implantes needed and their function? Looking to what type of bone healing?

Articular cartilage Composition: Chondrocytes Proteoglycan Type II collagen Water

Articular cartilage Articular cartilage: Resilient Elastic Avascular

Functions of articular cartilage Provides frictionless surface to joints Shock absorber Distributes forces evenly

Nutrition of articular cartilage Avascular Nutrition comes from synovial fluid Flow of synovial fluid requires motion and load

Articular cartilage response to trauma Very sensitive to injury Poor healing potential Heals with a mixture of fibrous tissue and fibrocartilage

History of treatment of articular fractures Immobilization of joint injury was common practice in the 19th and early 20th century Lambotte recommended: Anatomical reduction of the articular surface Alignment of the diaphyseal/epiphyseal fragments Sound fixation of the articular portion to the diaphysis Bone graft

History of treatment of articular fractures “Perfect anatomical restoration and perfect freedom of joint movement can be obtained simultaneously only by internal fixation.” Sir John Charnley, 1961

Clinical and experimental evidence Immobilization results in joint stiffness Immobilization after ORIF results in much greater stiffness

Outcome after articular fractures depends on: Trauma energy Residual malalignment Ligamentary instability Step-offs in articular cartilage

Treatment of articular fractures Anatomical reduction of fragments: No step-offs No depression No gaps Stable internal fixation Can withstand early mobilization Early motion of joint Important for hyaline cartilage healing Prevents stiffness

Principles of treatment Understand the injury Evaluation of soft tissues Preoperative planning Timing Articular reduction Buttress of metaphysis

Principles of treatment Understand the injury

Principles of treatment Understand the injury Evaluation of soft tissues

Principles of treatment Understand the injury Evaluation of soft tissues Preoperative planning: X-rays: AP, lateral, oblique CT MRI

Principles of treatment Understand the injury Evaluate soft tissues Preoperative planning Timing: Early (< 1–2 days) Late

Principles of treatment Early timing: Little edema Good skin condition Recent trauma < 2 days

Principles of treatment Timing: Avoid surgery after 3 days Soft tissue??

Principles of treatment Timing: Traction or external fixator

Principles of treatment Timing: Traction or external fixator Photos courtesy of Christoph Sommer, Switzerland

Principles of treatment Timing: Traction or external fixator Definitive fixation 1–2 weeks later Photos courtesy of Christoph Sommer, Switzerland Wrinkle signs

Principles of treatment Articular reduction Gaps more forgiving, step-offs dangerous.

Principles of treatment Buttressing of the metaphysis Depressed articular fractures Comminuted articular fractures Movement of the joint Mobilization of patient

Principles of treatment

Principles of treatment

Principles of treatment Explanation regarding the use of fine-wire fixation to augment management, to treat metaphyseal/diaphyseal component. Articular component still requires absolute stability and most often direct reduction technique.

Principles of treatment

Type of fixation

6 weeks postoperative Reduction? Stability? Implants? Healing?

Take-home messages Flow of synovial fluid requires motion and load Anatomical reduction Absolute stability  early mobilization  enhances healing Multiple types of fixations

Healing with hyaline cartilage Take-home messages Anatomical reduction + Absolute stability Early movement Healing with hyaline cartilage Respect soft tissues